Form 0920-0770 Recruiter Debriefing (English)

Attachment 3e
Recruiter Debriefing(English)

Form Approved:
OMB No. 0920-0770
Expiration Date: XX/XX/XXXX

National HIV Behavioral Surveillance System: Recruiter Debriefing
(IDU/HET Cycles)
Public reporting burden of this collection of information is estimated to average 2 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to: CDC,
Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0770).
Do not send the completed form to this address.
RQ1. How many of the coupons did you give out?
[Refused= 7, Don’t Know= 9] ___

RQ2. Has anyone refused the coupons?
No………………….……………………………  0
Yes………………………………………………  1

RQ3. Of those who refused coupons, how many were male?
[Refused= 7, Don’t Know= 9] ___
RQ4. Of those who refused coupons, how many were female?
[Refused= 7, Don’t Know= 9] ___
If RQ4 in (0, 7, 9) skip to RQ6.
RQ5. What is the race or ethnic background of those who refused coupons? That is…
a. How many were American Indian or Alaska Native?
___
b. How many were Asian?
___
c. How many were Black or African American?
___
d. How many were Hispanic or Latino?
___
e. How many were Native Hawaiian or Pacific Islander? ___
f. How many were white?
___

If NHBS-HET, skip to RQ7.

RQ6. Which of the following are reasons that people who refused gave you about why they did not
take a coupon? [Read each one. Check all that apply.]

1
They didn’t live in the area……………………..  2
They didn’t trust you (recruiter)..………………  3
They don’t like research/surveys……………….  4
They already participated in this survey…..…..  5
They didn’t want to be identified as IDU………  6
They weren’t eligible………….……………….  7
Some other reason (specify: __________)…….  8
Refused………………………………...…..…..  77
Don't know.……………..………….………......  99
They didn’t have time…………….……………

RQ7. Which of the following are reasons that people who refused gave you about why they did not
take a coupon? [Read each one. Check all that apply.]

1
They didn’t live in the area……………………..  2
They didn’t trust you (recruiter)..………………  3
They don’t like research/surveys……………….  4
They already participated in this survey…..…..  5
They weren’t eligible………….……………….  6
Some other reason (specify: __________)…….  7
Refused………………………………...…..…..  77
Don't know.……………..………….………......  99
They didn’t have time…………….……………